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Care planning in end of life care

2013 PHC Research Conference: Symposia abstract

Aims & rationale/Objectives
To describe the importance of care coordination between general practitioners, primary care services and specialist palliative care in end of life care, and research that is being conducted to support end of life care planning strategies.
End of life care is a core role for general practice and primary care services.It will become more critical as the population ages. It is not possible to rely on specialist palliative care services to care for all dying people, as specialist palliative care services mostly have cancer patients, and most people who die do not have cancer. For many conditions with a predictable end of life phase, the disease trajectory is unclear and care planning is difficult. The solution is to systematically identify people who might die of any cause, and systematically plan for problems that might arise when deterioration occurs. PC4 has supported two projects that address both the problem of case identification and that of care planning. Current thinking is that case identification is best accomplished using a systematic search of GP records using one of several tools publicly available. However, it has not been established whether the use of a tool is better than GP intuition in identifying patients at the end of life. This is being tested in a pilot RCT. Case conferences between GPs, a specialist nurse caring for the patient, and a medical specialist improves outcomes in populations of specialist palliative care. However, it has not been tested in a population of patients who have not been so referred. Pilot work has been completed and a formal RCT is being planned.
Relevance to conference theme
Multidisciplinary care planning may be a critical step for high quality are at the end of life
Presentation type
View webcast option  00:16:50
Mitchell G. (2013). Care planning in end of life care. In: 2013 Primary Health Care Research Conference: Program & Abstracts. Primary Health Care Research and Information Service, Australia.

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